CLINICOPATHOLOGIC CONFERENCE

J Oral Maxillofac Surg

61:824-826, 2003

Condylar Lesion
J.W. Hudson, DDS,* Kenneth W. Livesay, DMD,
and J. Michael McCoy, DDS
Case Presentation

and the nonossifying fibroma of bone. Of these 4, the

unicameral bone cyst is the most likely due to the fact
there is little, if any, cortical expansion caused by the
lesion. In addition, the lesion is very well circumscribed, which would mitigate against giant cell lesion
of bone as well as eosinophilic granuloma.
The common tumors that metastasize to the facial
bones include primary malignancies of the kidney,
lung, breast, colon, and prostate. All of these are
essentially tumors seen in adults. Childhood malignancies such as Wilms tumor, neuroblastoma, and central nervous system tumors can metastasize to bone,
but such a metastasis would be extremely rare without a known primary tumor.
The primary degenerative bone disease that can
form lytic, cyst-like lesions, would be osteoarthritis
(degenerative joint disease). This entity is extremely
rare in children, especially when no joint trauma is
involved. The radiograph should also show the more
common findings of osteoarthritis such as joint narrowing, cortical sclerosis, and flattening of the mandibular condyle.
Although the brown tumor of hyperparathyroism
can certainly present radiographically identical to this
case, almost all cases of such metabolic bone disorders are seen in adults. In addition, the other radiographic findings associated with hyperparathyroidism, such as loss of lamina dura and alterations in
bony trabecular patterns, are not seen in this case.
Taking into consideration the radiographic findings,
the clinical presentation of the patient, and the lack of
trauma association, one would strongly consider a benign primary bone lesion, either a cyst or a tumor. The
most likely would be the unicameral or traumatic bone
cyst because such lesions are relatively common. If
when the lesion underwent biopsy it proved to be solid
rather than cystic, then the most likely diagnosis would
be the nonossifying fibroma of bone. Both are completely benign and respond extremely well to curettage.
In fact, some authors suggest that no surgical intervention be indicated for either lesion.

A 13-year-old boy was initially referred for a coincidental

finding of a radiolucent lesion of the right condyle that was
noted on a computed tomography (CT) scan ordered by an
otolaryngologist for examination of the cochlear process
secondary to the patients mother complaint of a problem
with the childs hearing. The CT scan revealed a lytic lesion
in the head and neck region of the temporomandibular joint
(TMJ) condyle with mild cortical expansion but with no
gross appearance of erosion, although there did seem to be
cortical thinning in the pterygoid fossa (Figs 1, 2). A panoramic radiograph revealed a 1.2 0.5-cm uniocular radiolucent lesion located in the neck of the right mandibular
condyle (Fig 3).

Differential Diagnosis
J. Michael McCoy, DDS
The patient is a boy who radiographically demonstrates a minimally expansive, well-defined lytic lesion
of the mandibular condyle. This lesion was completely asymtomatic and thus only identified incidentally on a CT examination that was obtained for other
medical reasons. There is no historical evidence of
other medical problems and no history of trauma to
the region.
The differential diagnosis for such a lesion would
be divided into 1) primary bone tumors and cysts, 2)
metastatic lesions to bone, 3) degenerative bone lesions, and 4) metabolic bone lesions.
Primary bone tumors and cysts include the unicameral (traumatic, solitary) bone cyst, giant cell lesions
of bone, the bone lesions of eosinophilic granuloma,
*Professor, Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, Knoxville, TN.
Formerly, Chief Resident, Department of Oral and Maxillofacial
Surgery, University of Tennessee Medical Center, Knoxville, TN;
Currently, Private Practice, Duluth, GA.
Associate Professor, Departments of Pathology, Radiology, and
Oral and Maxillofacial Surgery, University of Tennessee Medical
Center, Knoxville, TN.
Address correspondence and reprint requests to Dr Hudson:
Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, 1930 Alcoa Hwy, Suite 335, Knoxville, TN
37920; e-mail: JWHudson@mc.utmck.edu

Subsequent Course
Subsequently, the patient was taken to the operating
room, where, under general anesthesia, a preauricular incision was made in the same fashion as a meniscectomy
incision for TMJ internal derangement might be used. The

2003 American Association of Oral and Maxillofacial Surgeons

0278-2391/03/6107-0012$30.00/0
doi:10.1016/S0278-2391(03)00157-5

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HUDSON, LIVESAY, AND MCCOY

FIGURE 1. Coronal maxillofacial computed tomography scan showing a lytic lesion at the head and neck region of the condyle.

FIGURE 3. Panoramic radiograph showing a uniocular radiolucent

lesion in the neck of the right mandibular condyle.

Pathologic Diagnosis
TMJ capsule was entered from the posterolateral aspect
through a horizontal incision. So as not to radically violate
the cortical plate of the condylar head, because the infrabony trabecular architecture had already been compromised, a bony window was developed with a No. 8 round
bur. Some of the contents of the condylar head were curretted under endoscopic visualization through a separate
port for evaluation by frozen section. The wound was then
aggressively curretaged under endoscopic visualization and
irrigated copiously, and the condylar head and neck were
then packed with freeze-dried collagen to provide better
clot matrix for spontaneous osteogenesis. At 18 months
postsurgical curettage and ablation of this lesion, bony consolidation and resolution of the lytic region of the condyle
without loss of structural cortical integrity were observed
(Fig 4). The patient has maintained a 45 mm maximum
incisal opening without deviation and good range of motion
without symptomatology.

The frozen section produced a histologic diagnosis

of a nonossifying fibroma (Figs 5, 6), which allowed
the surgical approach to proceed as previously described.

FIGURE 2. Axial maxillofacial computed tomography scan showing

a lytic lesion at the head and neck region of the condyle.

FIGURE 4. Panoramic radiograph taken 18 months postoperatively

with complete bony resolution of the right mandibular condyle.

Discussion
Discrete lesions of the TMJ are unusual, for both
malignant and benign pathoses. Nonossifying fibromas of the mandible are exceedingly rare, especially
with regard to these being localized in the condyle of
the TMJ. The clinical presentation of this lesion is
exceedingly subtle with no overt cortical expansion
or pain symptomatology that would help to direct the
diagnosis in different directions. Demographics of this
disease are focused in younger individuals not necessarily with an implicating etiology. There seems to be

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CONDYLAR LESIONDIAGNOSIS AND ENDOSCOPIC TREATMENT

FIGURE 5. Low-power photomicrograph of a lesion. Note the active

granulation tissue with numerous budding vessels (hematoxylin and
eosin stain, original magnification 40).

a predisposition of female gender for jaw lesions compared with a predilection of male gender for long
bone actual bone lesions. Eleven of these lesions were
reported as having occurred in the jaws as documented by a collective review by Bailey et al.1
Etiologically, these lesions appear to be a disturbance of growth or an aberrance of calcification compared with a true neoplasm. This heightens their
susceptibility to surgical manipulation with reorganization and consolidation with ossification. Clinically,
they are a nonsymptomatic, mildly cortical expansive
lesions with a radiographic appearance of radiolucency beneath a cortex that usually does not appear
to be grossly violated. Histologically, there are numerous fibroblasts in connective tissue with some variation between the giant cells, histiocytes, or foam cells
present, which historically has lead to various names
being associated with this particular lesion.2 Adding
to the collective world report on these lesions is this

presentation of a recent case of an intracondylar nonossifying fibroma of the TMJ.

Nonossifying fibroma was first recognized by Sontag and Pyle around 19413 and then formally placed
on the map by Jaffey and Lichtenstein in 1942.4 In
1972, the World Health Organization adopted a term
for the metaphyseal fibrous defect in which the lesion
was predominantly seen in the long bones of children. The most recent nonossifying fibroma of the
mandibular condyle was discussed by Aldred et al5 in
1989.
As described previously, the lesion is typically a
well-delineated, radiolucent infrabony lesion. When
found in the jaws, it has been limited to the condyle,
ramus, and coronoid process skeletal region of the
mandible. Predominance seems to be in children. The
gender predilection, at least for the jaw lesion, seems
to be female. Overall, the gender predilection is male.
Histologically, the nonossifying fibroma is relatively
ubiquitous save for occasional possible giant cell
and/or foam cell xanthomatous-type cell presentation. Given the histology, it appears that the lesion,
according to Hatcher6 and others, seems to be more
of a developmental disorder of intracondylar growth,
which again is why the lesion lends itself well to
conservative treatment.
The lesion is somewhat confounding in that there
are many lesions of the jaws that resemble this lesion.
However, its noncortical violation, asymptomatology,
and obviously the final histology are the defining
characteristics of the lesion itself.
Unique to this case was the treatment methodology. Once the lesion was identified histologically by
frozen section (and later confirmed by routine hematoxylin and eosin staining), the nature of the lesion
allowed a conservative approach using endoscopic
visualization for ablative curettement without gross
disruption of the condylar head as well as allowing for
intracapsular matrix augmentation using freeze-dried
collagen.

References

FIGURE 6. High-power photomicrograph of a lesion. Note the large

number of multinucleated giant cells mixed within the fibrous stroma
(hematoxylin and eosin stain, original magnification 200).

1. Bailey JS, Nikitakis NG, Lopes M, et al: Non-ossifying fibroma of

the mandible in a 6-year-old girl: A case report and review of the
literature. J Oral Maxillofac Surg 59:815, 2001
2. Bosch AL, Olaya AP, Fernandez AL: Non-ossifying fibroma of
bone. A histochemical and ultrastructural characterization. Virchows Arch A Pathol Anat Histol 362:13, 1974
3. Sontag LW, Pyle DI: The appearance and nature of cyst-like areas
in distal femoral metaphyses of children. Am J Roentgenol Radiat
Ther 46:185, 1941
4. Jaffe HL, Lichtenstein L: Non-osteogenic fibroma of bone. Am J
Pathol 18:205, 1942
5. Aldred MJ, Breckon JJW, Holland CS: Non-osteogenic fibroma of
the mandibular condyle. Br J Oral Maxillofac Surg 27:412, 1989
6. Hatcher CH: The pathogenesis of localized fibrous lesions in the
metaphyses of long bones. Ann Surg 122:1016, 1945